Healthcare Provider Details

I. General information

NPI: 1134876337
Provider Name (Legal Business Name): TIDEWATERHEALTH360 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1081 KEMPSVILLE RD
CHESAPEAKE VA
23320-8126
US

IV. Provider business mailing address

324 SAGE RD
VIRGINIA BEACH VA
23456-4419
US

V. Phone/Fax

Practice location:
  • Phone: 757-376-8460
  • Fax:
Mailing address:
  • Phone: 757-376-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT CORPIN CAJES
Title or Position: PRESIDENT
Credential: MD
Phone: 757-376-8460